Damage & Return Claim Form REVISED[1]

Con˜dential Page 1 Revised 7/07/2014 Claims Department DAMAGE & RETURN CLAIM FORM 2100 E Grand Ave., Suite 600 El Segundo, CA 90245 323.780.0859 | 323.780.0894 Fax Claim Number: C - SECTION I. GENERAL INFORMATION (Customer must ˜ll out Section I and Section II) Today’s Date: Customer Name: Account Number:

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